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I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
#71
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Thank you Dave.  I don't have any respiratory diseases that I know of.  No heart problems (CHF), but Cardiologist consult in a little over a week should rule out any heart problems like CHF.
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#72
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
I agree with Dave. This is textbook criteria for ASV, particularly the 2:1 ratio of CA to OA and low BMI and OSA risk factors of the patient. Thanks for posting results.
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#73
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Thank you Sleeprider for interpreting my results.  Sleeprider and Dave, I briefly glanced at the data.  I am no expert by any means.  The number that jumped out at me the most is 155 - the highest my heart rate got during wakefulness.  Am I going too long without breathing (combination of CA and OA) and my o2 sats fall low?  Or what mechanism is causing this.  This scares me.  By using 225 minus age to get maximum heart rate, I am close to my max at 175 or so.  And I am awake trying to fall asleep.  This is like running a lap around the track at full speed.  I am not aware of this in my body though.  Sure would be great to get this number way down.  I trust the ASV will do this.
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#74
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
During the study, the peak pulse rates mostly correlate with clusters of apnea.  The significant O2 desaturation at about midnight with arousal and Wake state was an obstructive cluster.  Nothing here looks out of place for your cardio-fitness, however clusters or long apnea will cause natural survival response that pumps adrenaline into your bloodstream. This increases respiration rate and volume as well as heart rate.  You are a young man with good fitness and BMI, but repeated episodes of adrenaline can weaken the heart in the long-term, resulting in problems like A-fib and other issues.  You are a long way from that based on everything we know.  Proper therapy should shield you from future health problems related to repeated respiratory issues and cardiac response.

This chart is your titration moving from CPAP to Bilevel. The end of your CPAP titration shows a sudden pressure rise at the time of the cluster of obstructive apnea. I will lay odds that was a positional apnea and would not have resolved with any pressure. After that, you were put on bilevel pressure without backup. This is actually associated with higher pulse rate and abundant central apnea. As the bilevel pressure was increased you have your first significant cluster of CA events at 02:37. IPAP pressure was kept constant and EPAP increased. At this time you have another cluster of mixed apnea. As IPAP moves above 11 or 12 cm you start having mostly central apnea from 03:15 to 04:00. This is a typical response to bilevel at higher pressures for someone with central apnea. It is at this point the medical practitioners screwed up. You needed a bilevel with backup rate, and that should have been called out. Had you been put on ASV at this point, you could have been put on EPAP 5.0, PS 3, with ASV pressure support, and your apnea would have fully resolved with resolution of obstructive events and all central events.

[Image: attachment.php?aid=38025]
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#75
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Ditto Sleeprider's thoughts.

If you've not had one, a test called echocardiogram will likely be needed to clear the way for ASV. It's a 30 ish minute ultrasound of the heart. Typically it'll be at a hospital in the imaging. You will pass fine. Tech does the test, cardiac doc reviews and signs, giving clearance for ASV. I did pass for ASV in '17, and I've got a few heart issues, high BP and PVC. My LVEF percentage was 55 and 63%, 45% and above passes.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#76
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Wow.  That's awesome.  Thank you so much Sleeprider and Dave.  I will talk about the echocardiogram with my PCP when I see her in 10 days to get the Cardiologist consult.  I will have a brochure for the ASV in hand to give to her also. (And I can have a copy of this page of my polysomnogram and show her and educate her about the clusters and need for the ASV also?)  Anything else I should push for or mention at the appointment in 10 days?  
You already have me titrated correctly from my polysomnogram.  My question is, how exactly should I proceed from here now that I know my correct titration numbers for the ASV bipap machine with back up?  Could I simply copy your post with polysomnogram screen shot above and give it to the RT with my DME company?  Would she be insulted?  I'm tempted to buy my own ASV out of pocket and start now, but I will play by the rules to keep my insurance coverage.    
This stuff seems like rocket science, and both of your experienced rocket scientists.
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#77
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
In the medical community the settings are prescription and as such the RT,DME, Sleep tech typically cannot change them from those values without the doctors permission. You can ask if it's ok to start with those settings.
When you get home you can change at will. In the end if you are in compliance, using it, and less than 5 AHI they will be happy.
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#78
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Not because I'm always right, but because it worked, I'll suggest how I got ASV on my docs radar in 2017.

Take your diagnosic report with you to your doctor. Highlight that area with the events type and count. Point that CA event and number out. You should tell doc you are concerned about the number of CA, that because you're concerned you researched what Central Apnea is, that as CA shown on this diagnosic it's not treatment emergent CA, and that CA is treated by ASV. Then you can ask what doc thinks, how can we remedy this CA? Then when doc says trying ASV Titration and the echocardiogram, you're almost there to your goal.

You can also state in an appropriate time your ASV choice is ResMed AirCurve 10 ASV.

CA is a 10 or more second cessation of breath without effort due to a too low CO2 level. The ASV can nudge you to breathe eliminating most CA. It also treats OA, Mixed, and Hypopnea.

The need for the echocardiogram is that there's a flawed test called SERVE-HF. It's supposed to be replaced with a better handled test.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#79
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
A brief background on the current warning for individuals with heart failure and a left ventricular ejection fraction less than 45% (LVEF < 45%).  The SERVE-HF study published in 2015 and enrolled in 2012 used older style ASV machines with fixed EPAP pressure on patients that were not titrated, or monitored for compliance. An unexplained but statistically significant risk of death from cardiac failure was found for a cohort that had severe heart failure and very low ejection fraction. Although the cause of these deaths was not identified, the study was discontinued and a recommendation to avoid ASV in heart failure patients with LVEF < 45% was issued. This warning was conservatively formulated, but fear of causing harm in patients led to a generalized rejection of ASV therapy for anyone, and we saw a return to ST machines.  Logically, where ASV is needed, the patients unable to be properly treated experienced deteriorating health and death from failing to treat their Cheyne-Stokes Respiration, central apnea and other significant respiratory problems.  

A new study was enrolled called ADVENT-HF which used more contemporary machines with auto-adjusting EPAP, titrated patients monitored for compliance.  That study failed to replicated the deaths or any severe illness in the cohort of severe HF patients with low LVEF.  I expected that the study would be published this past year putting an end to the ASV nonsense that we have been dealing with for the past five years, but we're still waiting.  It needs to be clearly understood, that the "warning" for ASV and requirement for echocardiogram testing is ONLY applicable to heart failure patients with risk factors consistent with the SERVE-HF study, not to healthy individuals like you.  Individuals with normal heart function or no known risk factors can move directly to titration and use for ASV. Out of an abundance of caution you may be asked to take the heart function tests, but it is really not necessary nor part of the guidance.  This is the Resmed flow-chart on the matter, followed by the ASV titration procedure.  While we are not practicing medical professionals on the forum, we generally take the position that in cases like yours, the use of clinical titration testing is unnecessary for someone that shows a need for ASV due to complex or central apnea without complicating pulmonary disease because the auto ASV algorithm automatically resolves both obstructive and central apnea without any input from a technician.  This is a major advancement over the older machines that did not have the auto-adjusting EPAP as mentioned above under the SERVE-HF discussion. It is sufficient to allow the patient to use ASV using default ASV Auto settings and determine optimization as needed, and establish patient benefit to the therapy after the trial.

[Image: attachment.php?aid=4251]

[Image: attachment.php?aid=4210]
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#80
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
SR would you make the above post a wiki article, adding references to the 2 studies and the titration guide, both external and internal in case the external url changes.

Thanks
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